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TST Referral Form v.2

This document appears to be a referral slip from the City Health Office in Valenzuela, Philippines referring a patient for tuberculin skin testing. It contains information such as the patient's name, age, sex, and address. It notes the reasons for referral, which include chest x-ray results, presence of signs and symptoms, and risk factors like household contact with contagious TB cases or being a child under 5 years old. It provides instructions for the schedule and location of the skin test and reading of results.

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John Philip Tiongco
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339 views3 pages

TST Referral Form v.2

This document appears to be a referral slip from the City Health Office in Valenzuela, Philippines referring a patient for tuberculin skin testing. It contains information such as the patient's name, age, sex, and address. It notes the reasons for referral, which include chest x-ray results, presence of signs and symptoms, and risk factors like household contact with contagious TB cases or being a child under 5 years old. It provides instructions for the schedule and location of the skin test and reading of results.

Uploaded by

John Philip Tiongco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES REPUBLIC OF THE PHILIPPINES


City Government of Valenzuela City Government of Valenzuela
City Health Office City Health Office
REFERRAL SLIP REFERRAL SLIP
Date: Date:
To: Valenzuela NTP To: Valenzuela NTP
From: From:
Name of Patient: Name of Patient:
Age: Sex: Address: Age: Sex: Address:

FOR TUBERCULIN SKIN TESTING FOR TUBERCULIN SKIN TESTING


Remarks: Remarks:
CXR 3/6 Signs & Symptoms CXR 3/6 Signs & Symptoms
Child less than 5y/o, who are HH contatct of CD TB case Child less than 5y/o, who are HH contatct of CD TB case
HH contact of BC TB case who are > 5y/o and with no other TB risk factors HH contact of BC TB case who are > 5y/o and with no other TB risk factors
close cotact of BC, outside the HH close cotact of BC, outside the HH
other risk groups - ongoing dialysis, organ transplant, initiation of anti-TNF, silicosis other risk groups - ongoing dialysis, organ transplant, initiation of anti-TNF, silicosis

RESULT: mm RESULT: mm
,MD ,MD
License No.: License No.:

Iskedyul ng TST: Tuwing Lunes, 8:00 ng umaga sa Main Laboratory ng Bagong Iskedyul ng TST: Tuwing Lunes, 8:00 ng umaga sa Main Laboratory ng Bagong
Valenzuela City Hall (sa likod ng Police Station) Valenzuela City Hall (sa likod ng Police Station)

Iskedyul ng TST reading at resulta: ang pasyenteng inikniksyunan ay dapat bumalik muli Iskedyul ng TST reading at resulta: ang pasyenteng inikniksyunan ay dapat bumalik muli
sa Main Laboratory ng Bagong Valenzuela City Hall (sa likod ng Police Station) paglipas ng 48 oras o sa Main Laboratory ng Bagong Valenzuela City Hall (sa likod ng Police Station) paglipas ng 48 oras o
Huwebes, 8:00 ng umaga ng kaparehong linggo. Ang mga pasyenteng hindi makakabalik sa takdang Huwebes, 8:00 ng umaga ng kaparehong linggo. Ang mga pasyenteng hindi makakabalik sa takdang
iskedyul ng reading ay makakatanggap na inbalidong resulta at ang testing ay uulitin muli. iskedyul ng reading ay makakatanggap na inbalidong resulta at ang testing ay uulitin muli.
"-------------------------------------------------------------------------------- "------------------------------------------------------------------------------
N T P C O P Y N T P C O P Y
Date: Date:

Return to: Return to:


From: Valenzuela NTP From: Valenzuela NTP
Name of Patient: Name of Patient:

RESULT: mm RESULT: mm
,MD ,MD
License No.: License No.:

REPUBLIC OF THE PHILIPPINES REPUBLIC OF THE PHILIPPINES


City Government of Valenzuela City Government of Valenzuela
City Health Office City Health Office
REFERRAL SLIP REFERRAL SLIP
Date: Date:
To: Valenzuela NTP To: Valenzuela NTP
From: From:
Name of Patient: Name of Patient:
Age: Sex: Address: Age: Sex: Address:

FOR TUBERCULIN SKIN TESTING FOR TUBERCULIN SKIN TESTING


Remarks: Remarks:
CXR 3/6 Signs & Symptoms CXR 3/6 Signs & Symptoms
Exposure: BC TB Source case CD TB source case Exposure: BC TB Source case CD TB source case
HH contact of BC TB case Child less than HH contact of BC TB case Child less than
who are > 5y/o and with 5y/o, who are HH who are > 5y/o and with 5y/o, who are HH
no other TB risk factors contatct of CD TB no other TB risk factors contatct of CD TB
case case

Close cotact of BC, Close cotact of BC,


outside the HH outside the HH

other risk groups - ongoing dialysis, organ transplant, initiation of anti-TNF, silicosis other risk groups - ongoing dialysis, organ transplant, initiation of anti-TNF, silicosis

RESULT: mm RESULT: mm
,MD ,MD
License No.: License No.:

Iskedyul ng TST: Tuwing Lunes, 8:00 ng umaga sa Main Laboratory ng Bagong Iskedyul ng TST: Tuwing Lunes, 8:00 ng umaga sa Main Laboratory ng Bagong
Valenzuela City Hall (sa likod ng Police Station) Valenzuela City Hall (sa likod ng Police Station)

Iskedyul ng TST reading at resulta: ang pasyenteng inikniksyunan ay dapat bumalik muli Iskedyul ng TST reading at resulta: ang pasyenteng inikniksyunan ay dapat bumalik muli
sa Main Laboratory ng Bagong Valenzuela City Hall (sa likod ng Police Station) paglipas ng 48 oras o sa Main Laboratory ng Bagong Valenzuela City Hall (sa likod ng Police Station) paglipas ng 48 oras o
Huwebes, 8:00 ng umaga ng kaparehong linggo. Ang mga pasyenteng hindi makakabalik sa takdang Huwebes, 8:00 ng umaga ng kaparehong linggo. Ang mga pasyenteng hindi makakabalik sa takdang
iskedyul ng reading ay makakatanggap na inbalidong resulta at ang testing ay uulitin muli. iskedyul ng reading ay makakatanggap na inbalidong resulta at ang testing ay uulitin muli.
"-------------------------------------------------------------------------------- "------------------------------------------------------------------------------
N T P C O P Y N T P C O P Y
Date: Date:

Return to: Return to:


From: Valenzuela NTP From: Valenzuela NTP
Name of Patient: Name of Patient:
RESULT: mm RESULT: mm
,MD ,MD
License No.: License No.:

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